Symptoms of a non-vital primary molar (3)

Irreversible pulpitisPeriapical periodontitisChronic sinus

Aim of a primary molar pulpectomy

Prevent/control infection by extirpation of radicular pulp followed by cleaning and obturation of canals

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Indication for a primary molar pulpectomy

Excellent patient cooperation

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Pulpectomy procedure (8)

Non-vital/hyperaemic pulpOpen roof of pulp chamberRemove contents of pulp chamberUse files to remove pulpal tissue from canals to 2mm short of estimated working length (EWL)Irrigate with chlorhexidine and dry with paper pointsObturate canals with Vitapex (CaOH and iodoform paste) or alternatively, a very thin mix of ZOESeal with thick mix of ZOE/GI and restore with PMCPost-treatment radiograph in clinical setting

CaOH placed in root canal to induce apical barrierSome concerns regarding long-term use of CaOH inside root canals – reduces mineral content of dentine and makes tooth more susceptible to root fractureRecent research may also suggest that some barriers formed in this manner are full of holesIn some cases, apical barrier formation using MTA may be the treatment of choice

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Process of apical barrier formation (4)

5mm of MTA should be placed at the apical end of the rootPlacement can be aided by use of a microscopePlacement is carried out using obtura probes, disposable MTA carriers or experimentally using a venflonWait at least 24 hours for MTA to harden then obturate with a heated GP system

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Vital mature tooth with pulp exposed (4)

Uses of CaOH (4)

Used to induce a calcific barrier following pulpotomy proceduresInduces barrier formation at apex of non-vital immature permanent incisors (apexification) - no longer treatment of choice but sometimes only practical option, takes around 9 months to completeUseful for decreasing microbial load in non-vital mature permanent teethUse now being advocated for 4-6 weeks only (inter-visit dressing) due to fact that CaOH makes root dentine brittle

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First aid of avulsed permanent teeth (7)

Store in fresh cold milk or salivaDo not allow to dry outCan wash for 10 seconds under cold water while holding only the crown if obvious debrisDo not handle to rootRe-implant quicklyFlexible splint for two weeksStart RCT after two weeks unless the tooth has an open apex and is replanted within 30-45 minutes

Placing a trauma splint procedure (4)

Cut and bend 0.6mm stainless steel wireApply composite resin to traumatised tooth and those adjacentSink the contoured, passive wire into the compositeShape and cure compositeSmooth rough composite and wire ends

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Definition of fissure sealant

Protective plastic coating used to seal fissures and pits to prevent food and bacteria getting caught in them and causing decay

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Why are fissures vulnerable to caries (2)

Fissures are less protected by fluoride than interproximal or smooth surfacesIt is not possible to clean the base of fissures with a toothbrush

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Materials used for fissure sealants (2)

Bis-GMA (mostly)Occasionally GIC

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Indications for fissure sealant placement (5)

High caries risk kids (permanents molars/premolars should be sealed on eruption)Medically compromised childrenChildren with learning difficultiesPhysically and mentally handicappedRecent SIGN 138 - all FPM in kids should receive FS

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Fissure sealants and low cares risk kids

If a child is of low caries risk they do not need to have their first permanent teeth sealed routinely, rather these fissures should be closely monitored

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Fissure sealant tooth selection (5)

Greatest benefit on occlusal surfaces of permanent molar teethShould also seal cingulum pits of upper incisors, buccal pits of lower molars and palatal pits of upper molarsSealing of primary molars may be advised in high caries risk childrenA child with caries in one first permanent molars should have the other three sealed immediatelyOcclusal caries in first permanent molars indicates that second permanent molars must be sealed on eruption

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Fissure sealant placement procedure (6)

IsolationAcid etchWashPlacementCheck placementReview

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Fissure sealant tooth isolation procedure (5)

Single tooth dental damDry guards and cotton woolRetraction and aspiration (dental nurse)Work with efficient speed to decrease the chance of moisture contaminationClean occlusal surface – preferably with pumice and water

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Fissure sealant acid etch procedure (2)

Use 35% orthophosphoric acid to etch enamel surfaceAvoid any etch touching the soft tissues, if it does rinse immediately as it could cause a burn

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Fissure sealant wash procedure (3)

Wash etch directly into aspiratory and dry the occlusal surface (3-in-1 syringe)Check that the etched surface has a chalky-white/frosted appearance when dryAny etched enamel not eventually covered with the sealant will remineralised within 24 hours

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Fissure sealant placement procedure (7)

Add the resin to the depths of the dry fissure patternCan use a brush, microbrush or small excavatorEnsure that material is in base of fissureAvoid overfilling as this will decrease long-term retentionExcess material can be removed with a dry microbrushShould be ‘spidery’ not ‘swimming pools’ Light cure the resin in accordance with manufacturers instructions

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Fissure sealant checking placement procedure (4)

Check sealant is firmly adhered (use sharp probe to try to dislodge)Check there are no air-blows present. If present, remove part of the sealant and re-doCheck that no material has flowed interproximally – if it has, remove with a sharp probe and dental flossCheck that there is no excess material distal to the tooth in the soft tissues

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Fissure sealant review procedure (2)

Review clinically every 4-6 monthsReview radiographically as per the patient’s caries risk assessment

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Indications for glass ionomer fissure sealant (2)

Where good moisture control cannot be achievedWhere there is a high degree of sensitivity die to developmental or hereditary enamel defects

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Types of kids where good moisture control cannot be achieved, so GIC FS should be used (3)

High risk children with partially erupted molarsSpecial needs childrenPoorly cooperating children

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Features of GIC FS (3)

Useful as release FPoorly retainedRequire regular reapplication

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GIC FS placement procedure (4)

Attempt to dry tooth with air or cotton woolApply GI from applicatorSmooth into fissures using gloved finger or thumbKeep finger over GI until set or place Vaseline to decrease moisture contamination until set

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Definition of stained fissure (2)

Fissure that is discoloured, brown or blackFissures where there is an area of white or opaque enamel(Normal translucency is lost but it has no evidence of surface breakdown - cavitation)

Management of virgin caries in FPMs (5)

Maximise preventionAlways prioritise FPM’s in any mixed dentition treatment plan (i.e. restore 6’s prior to dealing with lesions in primary molars)Caries most commonly affects the pits and fissures of the FPM’s but may also develop interproximally below the contact pointWhen caries in the FPM’s is extensive always consider the long-term prognosisRemember that the pulp is much more likely to be exposed on caries removal due to its size (may wish to consider stepwise caries removal in order to induce calcific barrier formation over the pulp)

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Indications for appropriate time to remove FPMs (4)

Beginning of bifurcation of the lower 7 is seen to be forming on an OPT (typically around 8.5-10 years of age)5’s and 8’s are all present and in a good position on the OPTMild buccal segment crowdingClass I incisor relationship